Pay for Quality

8 Pay for Quality KCE Reports 118
Because of these reasons and because of the high number of retrieved publications in
peer reviewed scientific literature as an input in the study, grey literature is excluded
from the systematic review.
After completion of the report, an additional search from January 2009 to July 2009 was
performed, to identify more recent relevant studies, which could be of value to our
report. The results of this additional search are described in appendix 16C.
2.1.1.2 Relevance screening
The following inclusion criteria were defined:
• Participants included health care providers in general primary and/or hospital
care, being a provider organization, team of providers or an individual
provider.
• The intervention is defined as policies, including laws, rules, financial or
administrative orders, made by governments, non-governmental organizations
(health funds, provider organizations,…), public or private insurers, that
specifically and directly intend to affect the quality of care, by means of
financial incentives. The intervention can be combined with other
interventions, conform the McKinley model 15 . It can comprise a financial
incentive directed at a person’s income or directed at further investment in
quality improvement. The financial incentive can be either positive or
negative. Target payments, paying the practice of professionals only if they
provide a minimum level of care, are considered a form of P4Q. Even if these
targets imply a volume or quantity (e.g. the % of patients vaccinated), these
indicators are still based on evidence based guidelines, intended to maximize
quality of care, making it distinct from an uncontrolled fee for service
approach not based on evidence based standards.
• Comparison is standard practice, i.e. without the presence of the above
described intervention.
• At least one objective process or (intermediate) outcome measure must be
reported on clinical effectiveness of care, interpersonal aspects of care,
patient safety, access and equity of care, continuity and/or coordination of
care or cost-effectiveness of care.
The following exclusion criteria were applied:
• Studies situated in mental health or behavioural health are excluded.
• Financial incentives aimed at patients do not comply with the P4Q concept.
This is a whole other array of research, mainly within the field of prevention
and changing lifestyle behaviour 15 , 16 .
• Papers only treating implicit financial incentives, which might influence quality
of care, but are not specifically intended as such to promote explicitly quality
in the first place, are excluded. Examples are studies on Fee For Service,
capitation, salary use, etc. As noted by Kane et al (2004): “Any provider fee
or reimbursement system within healthcare is by definition an economic
incentive” 15 .
• Subjective outcomes (qualitative research results, patient satisfaction, etc.)
are not included, unless they were measured using standardized validated
instruments.
• Papers only focusing on improving cost containment or productivity using
financial incentives, without a primary quality objective, do not pass the
PICOD requirements and are therefore excluded (see Lewandowski et al
(2006) as an example 17 ).
Appendix 3 and 4 list the reasons for excluding publications during full text review.